The history, examination and medical decision-making are normally the key components in selecting the level of evaluation and management (E/M) services. The exception is for visits that consist predominantly of counseling or coordination of care. To qualify for time-based coding, time needs to be the controlling factor for the visit.
If greater than 50% of a provider’s time for an E/M visit is spent face to face with the patient counseling and/or coordinating care, and there is detailed patient-specific documentation, then time can determine the level of the service.
If the total time falls between two levels, the provider’s time must be more than halfway to the next level to justify billing the higher-level code.
A new patient encounter in which the majority of time is spent on the history, patient exam, assessment and treatment plan should not be billed based on the length of time taken for the visit.
Examples of insufficient documentation
Two examples are given to demonstrate why the documentation is insufficient:
- “I spent 30 minutes face to face with the patient; greater than 50% of time was spent on counseling and coordination of care.”
The time statement cannot stand alone. The documentation must include a summary of the discussion with the pertinent details of the discussion.
- “Thirty-five minutes was spent face to face with the injured worker, greater than 50% of time was spent in counseling and coordination of care. Lengthy discussion with injured worker for return to work and expectations and specific goals.”
This documentation gives a summary but not enough detail about the discussion. What were the injured worker’s concerns about return to work? What were the specific goals and expectations? It’s insufficient to state a discussion occurred without including the details.
Per the Colorado Division of Workers’ Compensation, documentation that supports counseling and coordination of care will contain one or more of the following:
- Injury or disease education that includes discussion of diagnostic tests results and a disease-specific treatment plan
- A return-to-work plan and statement of temporary or permanent restrictions
- A review of other physicians’ notes
- Information on self-management of symptoms while at home and work
- Details on correct posture and mechanics needed to safely perform work functions
- A list of exercises for muscle strengthening and stretching
- Instructions on appropriate tool and equipment use to prevent re-injury or worsening of the existing injury or condition
- A review of the injured worker’s expectations and specific goals
- Information about family and other interpersonal relationships and how they relate to psychological or social issues
- A discussion of pharmaceutical management, including the drug dosage, the specific drug side effects and the potential for addiction or problems
- An assessment of vocational plans
For questions, contact Pinnacol’s medical bill auditors at email@example.com